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Junior Climbing Club Parental Consent 

Additional Activities
As part of the Junior Climbing Club we on occasion go off for additional activities. These activities include outdoor climbing days and visits / competitions at other climbing walls. This consent form will be used for these additional activities and there will be no additional consent forms requested from you for these activities and this consent form with medical and emergency details will be carried for all additional activities. Please note that should you sign your child up to an event that has transport included, you are also giving your consent for your child / children to travel in vehicles provided by Boulder Shack.

British Mountaineering Council (BMC) statment
I am aware that climbing, hill walking and mountaineering are activities with a danger of personal injury or death. I have understood the nature of the activity and accept the risk involved. I confirm I am the parent/guardian of the above named child and that I consent for him or her to take part in the children’s climbing club (and additional activities if signed up to) with Boulder Shack Climbing Gym. I consent to any emergency medical treatment necessary during the course of the events including the administration of anaesthetics.

Video Coaching
We sometimes use video recording as a coaching tool to help junior climbers review their technique. This is again in accordance with our child protection policy and all videos are taken and stored on Boulder Shack devices. Any video footage taken is deleated at the end of each term and will never be used for advertising or marketing.

Update of information
I am aware that this consent form is for the entire time my child is a member of the Junior Climbing Club. I will inform Boulder Shack Climbing Gym in writing of any changes to the information provided in this consent form.

Your Data

By participating at Boulder Shack Climbing Gym you accept that we will be keeping your data indefinatly, however at anytime you can ask for your data to be deleted. In the event of a First Aid form needing to be filled out we will be keep this information for 3 years (form your 18th birthday). We take protecting your data seriously, all of the data that we gather is kept in accorance with the Data Protection Act.  

Please click the box below to initial to confirm that you have read and understood the above information and that you are happy for your child to climb in the junior clmbing club at Boulder Shack Climbing Gym under these terms.

Dated: December 13, 2018

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail. Check to receive this news
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Medical Details*

Specify if "Yes" above

Doctor Surgery Name & Address
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. You can withdraw your consent at any time. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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